CPT CODES Q9981, Q9982 AND Q9983 WITH ZB modifier

Medicare providers and suppliers that effective for claims with dates of service on or after July 1, 2016, new Healthcare Common Procedure Coding System (HCPCS) codes Q9981 (rolapitant, oral, 1mg); 

Q9982 (flutemetamol f18 diagnostic); and Q9983 (florbetaben f18 diagnostic) will be payable for Medicare. In addition, the HCPCS code set will contain code Q5102 (Inj., infliximab biosimilar), which is effective for dates of service on or after April 5, 2016. 

Claims for Q5102 must also have the modifier ZB (Pfizer/hospira). Make sure that your billing staffs are aware of these changes.

The HCPCS code set is updated on a quarterly basis and CR9636 provides that effective July 1, 2016, the HCPCS codes contained in the following table will be established:

HCPCS Code Short Description Long Description  Type of Service (TOS) Code

Q9981 rolapitant, oral, 1mg Rolapitant, oral, 1 mg    1

Q9982 flutemetamol f18 diagnostic Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries    4

Q9983 florbetaben f18 diagnostic Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries    4

Also, as of July 1, the HCPCS code set will contain code Q5102 (short descriptor – Inj., infliximab biosimilar – and long descriptor – Injection, Infliximab, 10 mg). 

Code Q5102  will be effective for dates of service on or after April 5, 2016, and will have TOS codes of 1 and P. In addition, claims for Q5102 must also have the modifier ZB (Pfizer/hospira).

Coding tips for Diagnostic Imaging and Laboratory codes

Diagnostic Imaging

If the treating chiropractic provider refers the reading or interpretation of a radiology service to a radiologist, reimbursement for the professional component of that service will only be made to the radiologist, and the treating chiropractic provider should not bill for that component.

Component Modifier Description of Services

• Professional 26 Services rendered by a licensed practitioner to perform the diagnostic interpretation of each study. It is required to document the diagnostic conclusions of the study by a written and signed radiology report.

• Technical TC Radiology services that include providing the facilities, equipment, resources, personnel, supplies and support needed to perform and produce the diagnostic study.

• Global N/A Combines both the technical and professional components in the service provided.

Laboratory

BlueCare, BlueMedicare HMO, BlueMedicare PPO and BlueOptions members covered in-office laboratory services are restricted to:

81000, 81001, 81002, 82947, 82948, 85014, 85025 All other laboratory services should be referred to Quest Diagnostics, Inc.

For BlueChoice and Traditional members, members may be referred to any Florida Blue contracted laboratories, including Quest Diagnostics.

Laboratory services for select health and musculoskeletal conditions may comprise one or more of the procedure codes on the list of in-office laboratory codes. Reimbursement for routine venipuncture for collection of specimen (36415) is only payable when paired with modifier 90 and when the laboratory sample is drawn in the chiropractor’s office, but the sample is sent to an offsite laboratory for processing

Procedure codes with modifier 22 - Medicare internal issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.

Issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.

Resolution

First Coast is currently identifying the impacted claims and will begin to initiate adjustments on all impacted claims within the next two weeks. Claims having met medical necessity requirements will be changed to an unlisted surgical procedure code (modifier 22 will be appended to the related unlisted surgical procedure) to allow payment above the Medicare physician fee schedule. First Coast began utilizing this process July 11, 2014, for all surgical procedure billed with the 22 modifier that met medical necessity requirements for additional payment.

Procedure codes with modifier 22

 An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.

Issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.

How to avoid or preventing duplicate denial OA 18

Exact duplicate claim/service

(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)

(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)

(THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED)

(MORE THAN 1 E/M SERVICE BILLED ON THE SAME DAY)

Resources/tips for avoiding this denial

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.

• Click here to review article on new claim system edits regarding duplicate claims.

• Ensure necessary appropriate modifiers are appended to claim lines.

• Refer to the Modifier FAQs here on the First Coast Medicare provider website for additional information.

Preventing duplicate claim denials 

Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.

Molina covered Vaccines list

Vaccines for Recipients Birth through (18) Years 

For eligible recipients from birth through (18) years of age, vaccines and combination vaccines providing protection against the following diseases are available free to the VFC-enrolled provider through the VFC program:

  Diphtheria, Tetanus and Pertussis (DTaP)

  Haemophilus Influenzae Type b (HIB)

  Hepatitis B (pediatric and adult)

  Meningococcal Conjugate (MCV4)

  Pneumococcal (PCV 7)

  Polio (IPV)

  Measles, Mumps, and Rubella (MMR)

  Tetanus and Diphtheria (Td) (Adult)

  Influenza

  Varicella

  Human Papillomavirus (HPV)

  Rotavirus

The following vaccines are available by request or for high-risk areas only through the VFC program:

  Hepatitis A

  Diphtheria and Tetanus (DT) (Pediatric)

  Pneumococcal Polysaccharide (PPV)

  Meningococcal Polysaccharide (MPSV4)

Vaccines for Recipients (19) through (20) Years

For eligible recipients ages (19) through (20) years, vaccines and combination vaccines providing protection against the following diseases are reimbursable:

  Hepatitis A

  Hepatitis B

  Human Papillomavirus (HPV)

  Influenza

  Measles, Mumps, and Rubella (MMR)

  Meningococcal Conjugate (MCV 4)

  Meningococcal Polysaccharide (MPSV4)

  Pneumococcal Polysaccharide (PPV)

  Tetanus and Diphtheria (Td)

  Varicella

How to bill Lab, radiology and Venipuncture code with Modifier 26

Lab and Radiology Billing

When submitting claims for laboratory or radiology services rendered in a hospital setting, inpatient or outpatient, and you are a professional provider, use modifier 26 to indicate that you are billing for the professional component only. The hospital will submit claims for the technical component.

When submitting claims for laboratory or radiology services rendered in an office setting and you are a professional provider, indicate whether or not you are billing for the global fee or only the professional component. Use modifier 26 to indicate you are billing for the professional component only if sending the sample to a laboratory. You should also check “yes” in Box 20 of the CMS-1500 or 837 transaction. This allows payment to the laboratory for the technical component. If you don’t use a modifier and don’t indicate “yes” in Box 20 of the CMS-1500, you will be paid the

global fee. Should the laboratory subsequently bill for the technical component, that claim

will be denied.

Note: Clinical labs billing for services for inpatient hospital patients must bill the facility, not TRICARE, for the lab tests. Repeated failure to follow this rule will cause the clinical lab to have all claims returned to them without processing.

Anesthesia Modifiers - P1 - P6 modifier

Anesthesia Modifiers Including Physical Status Modifiers:

All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-01999) plus the addition of a physical status modifier. The use of other optional modifiers may be appropriate.

Physical Status Modifiers

Physical Status modifiers are represented by the initial letter 'P' followed by a single digit from 1 to 6

defined below:

P1 - A normal healthy patient.

P2 - A patient with mild systemic disease.

P3 - A patient with severe systemic disease.

P4 - A patient with severe systemic disease that is a constant threat to life.

P5 - A moribund patient who is not expected to survive without the operation.

P6 - A declared brain-dead patient whose organs are being removed for donor purposes.

The above six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in CPT to distinguish between various levels of

complexity of the anesthesia service provided.

Example: 00100-P1

Other Modifiers (Optional)

Under certain circumstances, medical services and procedures may need to be further modified. Other

modifiers commonly used in Anesthesia are included below. A complete list of modifiers and their

respective codes are listed in Appendix A.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually

required for the listed procedure, it may be identified by adding modifier '-22' to the usual procedure

number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia: Occasionally, a procedure which usually requires either no anesthesia or

local anesthesia, because of unusual circumstances must be done under general anesthesia. This

circumstance may be reported by adding the modifier '-23' to the procedure code of the basic service

or by use of the separate five digit modifier code 09923. Note: Modifier '-47', Anesthesia by

Surgeon, (see modifier section) would not be used as a modifier for the anesthesia procedures 00100-

01999.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg,

PRO, 3rd party payer) may be identified by adding the modifier '-32' to the basic procedure, or the

service may be reported by use of the five digit modifier 09932.

Anesthesia billing services - BCBS

Anesthesia Payment & Billing Information - BCBS

Time and Points Eligible Anesthesia Procedures Defined

HMO Blue Texas and Blue Cross and Blue Shield of Texas have determined that certain anesthesia procedures will be reimbursed on time and points methodology.

Procedures that are not included on the Anesthesia Time & Points Eligible List will not be reimbursed using time and points methodology. If a procedure is not on this list, and it is submitted using anesthesia indicators for Time & Points such as:

using an anesthesia modifier, or

using time on the claim, or

 if submitted on a non-HIPAA claim format, (Type of Service = 7) then the provider may receive a denial message for that procedure noting that the service is not eligible for time and points payment methodology.

Anesthesia Services

Services involving administration of anesthesia should be reported by the use of the Current Procedural Terminology (CPT) anesthesia five-digit procedure codes, American Society of Anesthesiologists (ASA) or CPT surgical codes plus a modifier. HMO Blue Texas and Blue Cross and Blue Shield of Texas will require that the appropriate anesthesia modifier be filed on anesthesia

services.

An anesthesiologist or a CRNA can provide anesthesia services. The anesthesiologist and the CRNA can bill separately for anesthesia services personally performed. When an anesthesiologist provides medical direction to a CRNA, both the anesthesiologist and the CRNA should bill for the

appropriate component of the procedure performed. Each provider should use the appropriate anesthesia modifier.

In keeping with the American Medical Association Current Procedural Terminology (CPT) Book, services involving administration of anesthesia include the usual pre-operative and post-operative visits, the anesthesia care during the procedure, the administration of fluids and/or blood and the usual monitoring services (e.g., ECG, temperature, blood pressure, oximetry, capnography and mass spectrometry). Intra-arterial, central venous, and Swan-Ganz catheter insertion are allowed separately.

Modifier Information Billed by an Anesthesiologist 

AA Anesthesia services personally performed by the anesthesiologist

AD Supervision, more than four procedures

QK Medical Direction of two, three or four concurrent anesthesia procedures

QY Medical Direction of one CRNA by an anesthesiologist

Modifier Information Billed by a CRNA

QX Anesthesia, CRNA medically directed

QZ Anesthesia, CRNA not medically directed

BCBS - Anesthesia Modifier reimbursement

Anesthesia Payment & Billing Information - BCBS

Anesthesia Modifier Reimbursement :

Effective for dates of service on or after May 19, 2004, the HMO Blue Texas and Blue Cross and Blue Shield of Texas maximum allowable fees for services billed as MD supervision of a CRNA are as follows:

QY MD supervision of a CRNA $325.52

QK MD supervision of a CRNA $310.01

AD MD supervision of a CRNA $162.76

OB Time and Points Maximum Allowable Points : 

The following are the current HMO Blue Texas and Blue Cross and Blue Shield of Texas total maximum allowable points for Vaginal or Cesarean deliveries:

Obstetrical Vaginal delivery: 23 total maximum allowable points

Obstetrical Cesarean delivery: 32 total maximum allowable points

If general anesthesia is used in the performance of any obstetrical Vaginal or Cesarean delivery, the maximum allowable points are applicable. In the event that total actual points are less than the total maximum allowable points, you will be reimbursed based on total actual points.

Reimbursement of OB Anesthesia Add-On Codes 01968 and 01969 :

When a primary OB delivery anesthesia procedure (01967) is billed with either 01968 and/or 01969, HMO Blue Texas and Blue Cross and Blue Shield of Texas allows a combined maximum of 32 points.

Aneshthesia Time-Based Units

During the first 4 hours of service, 15 minutes equals 1 unit. If services are provided for longer than 4 hours in one occurrence, each 10-minute period after the initial 4 hours equals 1 unit. A period less than a unit should be rounded up to the next unit.

Example A: 5 hours or 300 minutes equals 22 units – 16 units for the first 4 hours (1 unit per each 15 minutes) and 6 units for the last hour

(1 unit per each 10 minutes).

Example B: 128 minutes is billed as 9 units (8 units for the first 120 minutes and 1 additional unit for the remaining 8 minutes).

Completing the Claim Form

The following instructions are specific to anesthesia services and must be used in conjunction with the complete CMS-1500 Claim Form Instructions provided on First Health Services’ website (select “Billing Information” from the “Providers” menu).

· Field 19: When billing a time-based code, enter the total minutes of reportable anesthesia time in Field 19.

· Field 24D: On the bottom, white half of the claim line, enter one CPT code and one physical status modifier (P1-P6). List additional modifiers when appropriate.

· Field 24G:

o When using a time-based code, enter the number of reportable anesthesia time units; do not add base units or modifier units to the time units.

o When using an occurrence-based code, enter a “1” for each occurrence. The following codes are paid per occurrence: 01953, 01967, 01968, 01969, 01996, 99100, 99116, 99135 and 99140.

Anethesia billing - Introduction

Anesthesia care conventionally includes all services associated with the administration of analgesia/anesthesia, provided by an anesthesiologist and/or certified registered nurse anesthetist (CRNA)1 to a patient undergoing a surgical or other invasive procedure so that intervention can be undertaken. This may involve local, regional, epidural, general anesthesia or monitored anesthesia care (MAC), and usually involves administration of anxiolytics or amnesia-inducing medications. 

Additionally, anesthesia care includes preoperatively evaluating the patient with a sufficient history and physical examination so that the risk of adverse reactions can be minimized, planning alternative approaches to accomplishing anesthesia and answering all questions regarding the anesthesia procedure asked by the patient.

The anesthesiologist assumes responsibility for the post anesthesia recovery period which is included in the anesthesia care package. It encompasses all care until the patient is released to the surgeon or another physician; this point of release generally occurs at the time of release from the post anesthesia recovery area.

payment formula when we apply modifier 54

Modifier 54

54 Modifier Surgical Care Only: One physician performs a surgical procedure and another provides preoperative and/or postoperative management. The Medicare Physician Fee Schedule Database (MPFSDB) gives percentages that apply to pre and intraoperative services.

Use the 54 modifier when one physician performs a surgical procedure and another provides preoperative and/or postoperative management, or the postoperative management is split between the surgeon and another practitioner. Place this modifier after the CPT code for the surgeon who is doing the surgery and not the entire patient follow-up.

Surgical Co-Management (Modifiers 54 and 55)

Medicare covers surgical co-management for appropriate reasons such as inability of the operating surgeon to provide postoperative care, inability of the patient to return to see the operating surgeon in the postoperative period for a variety of reasons or patient preference. For example, one physician may perform the surgery, but another physician may provide the follow-up care. Medicare will pay no more than the total fee schedule approved amount for the surgical procedure regardless of the number of physicians involved. Co-managed care should always adhere to the basic tenets of good patient care, the ethical responsibilities of providers and governmental rules.

When physicians agree on the transfer of care during the global period, use the following modifiers:

* 54 for surgical care only.

Or,

* 55 for postoperative management only.

Providers do not need to specify on the claim that the care has been transferred. However, the date on which care was relinquished or assumed, as applicable, must be shown on the claim. This should be indicated in the remarks field/free text segment on the claim form/format. Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. (Pub. 100-4, Chapter 12, Section 40.2 of the Internet-Only Manual (IOM)).

When a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he assumes care of the patient.

Usage of Modifier 24 with surgical cpt codes

GLOBAL SURGERY MODIFIERS

Use the following modifiers pertaining to global surgery:

Modifier 24

24 Modifier Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: Physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.

An E/M service can be coded with modifier 24 to indicate a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is not valid when coded with surgeries or other types of services. It is not appropriate for modifier 24 to be coded with diagnostic tests performed in the postoperative period. These are not part of the global surgical allowance and are always considered separately.

In most cases, diagnosis codes that apply to the E/M service are different from the diagnosis codes indicated on the original procedure. However, in rare circumstances, the diagnoses are the same, but the services are unrelated; if so, this information should be documented with the claim, either in the narrative field on electronic claims or on an attachment with paper claims.

Hospital visits by the surgeon during the same hospitalization as the surgery are considered related to the surgery; however, separate payment for such visits can be allowed if one of the following conditions applies:

* Immunotherapy management furnished by the transplant surgeon. Immunosuppressant therapy following transplant surgery is covered separately from other postoperative services. That is, postoperative immunosuppressant therapy is not part of the global fee allowance for the transplant surgery. This coverage applies regardless of the setting.

* The surgeon provides critical care for a burn or trauma patient.

* The diagnosis is unrelated to the original surgery.

Outpatient visits during the postoperative period are allowed during a global fee period if the claim documentation demonstrates that the visit is for a diagnosis unrelated to the original surgery. Use modifier 24 in this situation.

Office visits during the postoperative period are not covered unless they are submitted with modifier 24 to indicate they are unrelated to the surgery. Modifier 24 is primarily for use only by the surgeon. A different diagnosis code may be sufficient to show the procedure is unrelated to the surgery; however, it may not be required. Documentation submitted should fully explain how the E/M service is unrelated to the surgical procedure.

Usage of Modifier - 24

Medical Coding - Modifier -24 --

Unrelated Evaluation and Management Service by the SamePhysician During Postoperative Period

Report E/M code 99213 with Modifier -24 if the patientcame back during the postoperative period. The physician must identifythis service as completely unrelated with the recent procedure done onthe patient. A detailed medical documentation is a good support formedical necessity.

Example:

A patient had a procedure, let's say, had an epidural 64483. The patient came back to the office after 2 days. The physician saw the patient and must bill an E/M code with modifier 24 if this encounter is completely unrelated to the procedure done 2 days ago. If this encounter is related to the procedure, you are not to bill the said E/M service because of the global package for the procedure. A follow up visit is always included during the global period.

Rules for Modifier 24 usage

Modifier 24 - Unrelated evaluation and management by the same physician during a postoperative period

The following rules apply:

    * Modifier 24 is applied to only two possible code sets: evaluation and management (E/M) services (99201-99499) or general ophthalmological services (92002-92014), which are eye examination codes.

    * Modifier 24 is not valid with surgical procedures, labs, x-rays, or supply codes.

    * The new E/M service or eye exam usually involves a different diagnosis, but not always. For example, the same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.

    * Modifier 24 is not used to report exams performed for routine postoperative care.

    * Modifier 24 is an information modifier.

Example

Dr. Smith sees an established patient in his office who had a bike accident. Dr. Smith performs an intermediate repair for a 4.0cm wound on the patient’s forehead. The repair has a 10-day global period. 

Three days later, the patient sees Dr. Smith complaining about sinus trouble. Dr. Smith performs a problem focused exam and diagnoses the patient with a sinus infection. He writes a prescription and codes the visit as a 99212-24.

24 Modifier usage with related diagnosis and unrelated DX

24 Modifier

Unrelated evaluation and management service by the same physician during a postoperative period

Use modifier 24 when an E/M service is performed during a postoperative follow-up period for reasons unrelated to the original minor or major procedure. The physician must indicate that the services billed are unrelated and not part of the postoperative diagnoses.

Examples of Related Diagnoses

Example 1: A surgical claim was billed with ICD-9-CM code 1622 (malignant neoplasm of trachea, bronchus and lung; main bronchus). Ten days later, a claim (for dates of service 10 days after a 90-day global surgery) is submitted by the same physician for an office visit and the ICD-9-CM used on the claim is 486 (pneumonia, organism unspecified).

This E/M service would be considered part of the global period and would not be payable.

Example 2: A surgical claim was billed with ICD-9-CM code 59653 (paralysis of the bladder). Eighty days later, a claim (for dates of service 80 days after a 90- day global surgery) is submitted by the same physician for an office visit and the ICD-9-CM code used on the claim was 78900 (abdominal pain, unspecified site).

This E/M service would be considered part of the global period and would not be payable.

Examples of Unrelated Diagnoses

Example 1: A surgical claim is billed with ICD-9-CM code 38421 (central perforation of tympanic membrane – ear drum). Two months later (during the 90-day global period), an E/M service is billed with ICD-9-CM code 3804 (impacted cerumen – ear wax).

This E/M service would be considered unrelated and would be payable.

Example 2: A surgical claim is billed with two 90-day global surgical codes for date of service July 9. The ICD-9-CM diagnoses submitted on the claim are 5533 (diaphragmatic hernia) and 56210 (diverticulosis of colon). An E/M service is performed and billed for date of service July 26. The ICD-9-CM codes submitted are 7872 (dysphagia – difficulty in swallowing), 7015 (other granulation tissue) and 78079 (other malaise and fatigue).

This E/M service would be considered unrelated and would be payable. If the E/M service is unrelated to the postoperative follow-up period, modifier 24 is appropriate.

surgical CPT code with modifier 25 - example of usage

Modifier 25

25 Modifier Significantly Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. 

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the 25 modifier to the appropriate level of E/M service.

Medicare requires that CPT modifier 25 should only be used on claims for evaluation and management services, and only when these services are provided by the same physician (or same qualified non-physician practitioner) to the same patient on the same day as another procedure or other service. 

Medicare pays for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre and postoperative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier 25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

Modifier 25 Examples

Example 1: The patient sees the physician for knee pain. After examining the patient, meeting the criteria for the E/M and making the determination at the time of the visit that the patient needs a joint injection, the physician may use the 25 modifier on the office visit and be paid for the injection also.

Example 2: The physician tells the same patient in Example 1 to come back to his office in two weeks for another injection for the same complaint. He may not bill an office visit with the 25 modifier along with the joint injection. He may only bill the joint injection because this was planned prior to the visit and the criteria for an E/M service would not have been met.

Example 3: An office visit and suturing a scalp wound could be properly billed together with the use of a 25 modifier if a full neurological examination was made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status. In the circumstance when the decision to perform a minor procedure is typically done immediately before the service (e.g., whether or not sutures are needed to close a wound, whether or not to remove a mole or wart, etc.), it is considered a routine preoperative service and a visit or consultation should not be reported in addition to the procedure.

Important Modifiers with definition and when to use

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service:

The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. 

The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same day. This circumstance may be reported by adding the modifier '-25' to the appropriate level of E/M service, or the separate five digit modifier 09925 may be used. 

Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier '-57'.

The rules of 25 Modifier usage

25 Modifier

Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

Indicates on the day of a procedure or other service, the patient's condition required a significant, separately identifiable Evaluation and Management (E/M) service above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure that was performed. This modifier should only be used if an E/M is being billed on the same day as a procedure.

Correct Use

This modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery.

Documentation in the patient's medical record must support the use of this modifier.

This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99321-99323 and 99341-99345. These codes are listed as new patient codes and are automatically excluded from the global surgery package. They are reimbursed separately from surgical procedure and no modifier is required. 

New patient CPT codes required CPT modifier 25 when a separately identifiable E/M service is performed the same day as chemotherapy or non-chemotherapy infusions or injections as these are not considered surgery.

No supporting documentation is required with the claim when this modifier is submitted.

A different ICD-10 code from the one submitted with the minor surgery is not required with the E/M code. The diagnosis for the E/M service and the other procedure may be the same or different.

This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under the National Correct Coding Initiative (NCCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.

Incorrect Use

A physician other than the physician performing the procedure. Documentation shows the amount of work performed is consistent with that normally performed with the procedure.

The following conditions must be met to report modifier 25:

*  The patient’s condition required a significant, identifiable E/M service above and beyond the other service provided or services beyond the usual preoperative and postoperative care associated with the procedure that was performed.

*  These circumstances may be reported by adding the 25 modifier to the appropriate level of the E/M service.

1. The phrase, “the patient’s condition required” is extremely important. In other words, it was medically necessary for the patient to have these extra services on the same day that another procedure or service was performed.

2. The phrase, “a significant, separately identifiable E/M service above and beyond” the other service provided indicates that this extra service was clearly different from the other procedure or service that was performed.

3. The phrase, “services beyond the usual preoperative and postoperative care” associated with the procedure emphasizes the fact that all procedures as defined in the Resource-Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. 

The 25 modifier should be used if extra work beyond the usual is performed. A good standard for judging whether the 25 modifier should be used is: If a physician in the same specialty area would agree after reading the clinical record that extra preoperative and/or postoperative work beyond what is usually performed with that service was performed, then it is proper to use the 25 modifier to indicate that extra work. To document the extra work performed, the clinical record should clearly indicate that extra or unusual work.

Primary considerations for modifier 25 usages are:

 Why is the physician seeing the patient?

o If the patient exhibits symptoms from which the physician diagnoses the condition and begins treatment by performing a minor procedure or an endoscopy on that same day, modifier 25 should be added to the correct level of E/M service.

o If the patient is present for the minor procedure or endoscopy only, modifier 25 does not apply.

o If the E/M service was to familiarize the patient with the minor procedure or endoscopy immediately before the procedure, modifier 25 does not apply.

*  If the E/M service is related to the decision to perform a major procedure (90-day global), modifier 25 is not appropriate. The correct modifier is modifier 57, decision for surgery.

*  When determining the level of visit to bill when modifier 25 is used, physicians should consider only the content and time associated with the separate E/M service, not the content or time of the procedure.

Guidelines

1. Should a separately identifiable E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, information substantiating the E/M service must be clearly documented in the patient’s medical record, to justify use of the modifier –25.

2. Modifier –25 may be appended only to E/M service codes and then only for those within the range of 99201-99499. For outpatient services paid under OPPS, the relevant code ranges are:

99201-99215 (Office or Outpatient Services)

99281-99285 (Emergency Department Services)

99291 (Critical Care Services)

99241-99245 (Office or Other Outpatient Consultations)

NOTE: For the reporting of services provided by hospital outpatient departments, off-site provider departments, and provider-based entities, all references in the code descriptors to “physician” are to be disregarded.

Example: A patient reports for pulmonary function testing in the morning and then attends the hypertension clinic in the afternoon. The pulmonary function tests are reported without an E/M service code. However, an E/M service code with the modifier –25 appended should be reported to indicate that the afternoon hypertension  clinic visit was not related to the pulmonary function testing.

3. Medicare requires that modifier –25 always be appended to the emergency department (ED)E/M code (99281-99285) when provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure(s).

Example #1: A patient is seen in the ED with complaint of a rapid heartbeat. A 12-lead ECG is performed.

In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25 - 93005 (Twelve lead ECG)

Example #2: A patient is seen in the ED after a fall. Lacerations sustained from the fall are repaired and radiological x-rays are performed.

In this case, the appropriate code(s) from the following code ranges can be reported:

99281-99285 (Emergency Department Services) with a modifier –25 - 12001-13160 (Repair/Closure of the Laceration) - 70010-79900 (Radiological X-ray)

4. When the reporting of an E/M service with modifier –25 is appropriate (that is, the documentation of the service meets the requirements of the specific E/M service code), it is not necessary that the diagnosis code for which the E/M service was rendered be different than the diagnosis code for which the diagnostic

Modifier 25 Frequently Asked Questions

1. What is the definition of a “Modifier”* A modifier is a two-digit numeric or alphanumeric character reported with a HCPCS code, when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level I (Physicians’ Current Procedural Terminology [CPT®]) and HCPCS Level II codes.

2. What are the uses of Modifiers?

According to the 2015 CPT© professional Code Book, a modifier provides the means to report or indicate that a service or procedure that has been performed had been altered by some specific circumstances but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.

3. What is Modifier 25?

Modifier-25 is used for an unrelated evaluation and management (E/M) by the same provider or other qualified health care professional that is a significant, separately identifiable services performed on the same day as another procedure or service. 

The physician must show, by documentation in the medical record, that on the day a procedure was performed, the patient’s condition required a separately identifiable E/M service above and beyond the usual care associated with the procedure that was performed. A significant, separately identifiable E/M service is substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported.

4. What are some of the appropriate usages of Modifier 25?

• Use modifier 25 on an E/M service when performed at the same session as a preventive care visit when a significant, separately identifiable E/M service is performed in addition to the preventive care.

• The E/M service must be carried out for a nonpreventive clinical reason, and the ICD-9- CM code(s) for the E/M service should clearly indicate the nonpreventive nature of the E/M service.

• Attach modifier 25 to the E/M code representing a significant, separately identifiable service performed on the same day as routine foot care. The visit must be medically necessary.

• Modifier 25 indicates that on the day of a procedure, the patient's condition required a significant, separately identifiable E/M service, above and beyond the usual pre and postoperative care associated with the procedure or service performed.

• Use Modifier 25 with the appropriate level of E/M service.

• The procedure performed has a global period listed on the Medicare Fee Schedule Relative Value File.

• An E/M service may occur on the same day as a procedure and within the post-operative period of a previous procedure. Medicare allows payment when the documentation

supports the 25 modifier and the 24 modifier (unrelated E/M during a post-operative period.)

• Use modifier 25 when the E/M service is separate from that required for the procedure and a clearly documented, distinct and significantly identifiable service was rendered.

• When using 25 on an E/M service on the same day as a procedure, the E/M service must have the key elements (history, examination, and medical decision making) welldocumented. NOTE: However, although CPT does not limit this modifier to use only with a specific type of procedure or service, many third-party payers will not accept modifier 25 on an E/M service when billed with a minor procedure on the same day

 5. Can you use Modifier 25 for an unexpected incident or unplanned reason?

If, during the course of the preventive medicine visit, an abnormality or preexisting problem is addressed, physicians may receive payment for that part of the visit; however, the problem should be significant enough to warrant additional work that meets the requirements of at least a problem oriented E&M visit. In this case, that part of the visit may be billed by using the appropriate office/outpatient service code with the modifier 25 (significant, separately identifiable E&M service by the same physician, same day) along with the preventive medicine code.

6. What is the most common use of Modifier 25 for EPSDT (THSteps) checkups* 

The most common use of Modifier 25 associated to a THSteps checkup is when an immunization or vaccination is administered. Modifier 25 is used to indicate that the immunization or vaccination is an E/M service that was performed at the same session as a preventive care visit.

The use of Modifier 25 appended to the claim form shows (along with documentation in the medical record) that a significant, separately identifiable E/M service was performed in addition to the checkup.

7. What are the requirements for using Modifier 25*

The use of modifier 25 has specific requirements.

• The E/M service must be significant. The problem must warrant physician work that is medically necessary. This can be defined as a problem that requires treatment with a prescription or a problem that would require the patient or family to return for another visit to address it. A minor problem or concern would not warrant the billing of an E/M-25 service.

• The E/M service must be separate. The problem must be distinct from the other E/M service provided (e.g., preventive medicine) or the procedure being completed. Separate documentation for the E/M-25 problem is helpful in supporting the use of modifier 25 and especially important to support any necessary denial appeal.

• The E/M service must be provided on the same day as the other procedure or E/M service. This may be at the same encounter or a separate encounter on the same day. • Modifier 25 should always be attached to the E/M code. If provided with a preventive medicine visit, it should be attached to the established office E/M code (99211–99215).

• The separately billed E/M service must meet documentation requirements for the code level selected. It will sometimes be based on time spent counseling and coordinating care for chronic problems.

• A comment from the child or parent turns an encounter that was scheduled as a preventive medicine visit into something more. According to CPT, separate, significant physician

evaluation and management (E/M) work that goes above and beyond the physician work normally associated with a preventive medicine service or a minor surgical procedure is additionally billable.

8. What are incorrect uses of Modifier 25*

• Using modifier 25 to report an E/M service that resulted in the decision to perform major surgery (see modifier 57).

• Billing an E/M service with modifier 25 when a physician performs ventilation management in addition to an E/M service.

• Using modifier 25 on an E/M service performed on a different day than the procedure.

• Using modifier 25 on the office visit E/M level of service code when on the same day a minor procedure (e.g., an endometrial biopsy) was performed, when the patient’s trip to the office was strictly for the minor procedure (e.g., biopsy).

9. Where should Modifier 25 be placed on the claim form*

Modifier 25 is appended to an Evaluation and Management (E&M) service (never to a procedure code) to indicate a significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of a procedure or other service was provided.

10. How do I know if the extra work is “significant” and therefore, additionally billable* 

Since CPT does not define “significant,” asking yourself the following questions should lead you to the answer:

• Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem*

• Could the complaint or problem stand alone as a billable service*

• Is there a different diagnosis for this portion of the visit*

• If the diagnosis will be the same, did you perform extra physician work that went above and beyond the typical pre- or postoperative work associated with the procedure code*

Insurance’s Policy for Modifier 25

If the provider provides both a service or procedure and an evaluation and management (E&M) on the same day, it must be significant, separate, and identifiable. Documentation must support both services and show that the E&M was above and beyond the service or procedure provided.

When preventive care codes 99381-99387 or 99391-99397 are billed with office visit codes 99201-99203 or 99211-99213 (with modifier 25 on the office visit code) chart notes are not needed; both codes will be allowed. For all other preventive care & office visit code combinations (or these combinations  billed without modifier 25), chart notes are required for consideration of both codes.

When the original claim is received with both preventive services and office visit charges:

• The system will stop the claim for review to allow the adjudicator to determine if chart notes are attached to the claim.

• If there are no chart notes submitted, the charges for the medical office visit will be considered provider write-off. If notes are attached, the notes will be reviewed and, based on the content, a determination will be made whether or not the office visit is appropriate.

• Claims received as rebills with notes will be forwarded to a Claims Research Analyst.

Examples

Examples of when both charges would not be appropriate:

• A patient who has a history of hypertension is scheduled for a routine physical. You make brief mention of the hypertension and re-fill the patient’s prescription.

• During an annual gynecological exam, a patient mentions that she is having hot flashes, and you order blood work to check hormone level.

• A child is seen for a well-child checkup and you note  at he has an ear infection and prescribe antibiotics. Examples of when both charges would be appropriate:

• A patient is scheduled for a routine physical with a history of hypertension, and upon examination, you discover that the patient’s blood pressure is extremely high. The patient  says he is having lightheadedness and ringing in the ears. You take measures to reduce the blood pressure and  counsel the patient on how to monitor the condition.

• During an annual gynecological exam, you find a lump in a patient’s breast and order additional blood work and radiological procedures. You also take additional time to go over treatment options with the patient.